Healthcare Provider Details

I. General information

NPI: 1568896041
Provider Name (Legal Business Name): KELLY KOZIATEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W NORTHERN AVE
PHOENIX AZ
85021-4918
US

IV. Provider business mailing address

2301 W NORTHERN AVE
PHOENIX AZ
85021
US

V. Phone/Fax

Practice location:
  • Phone: 602-866-9378
  • Fax:
Mailing address:
  • Phone: 602-866-9378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: